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Removable dental prosthesis use and low handgrip strength in Korean adults: a nationwide
cross-sectional study
Jae-Hyun Lee, DMD, MSD, PhDa,b, Su Young Lee, DDS, MSD, PhDc,*, Kyungdo Han, MS,
PhDd, Jung-Suk Han, DDS, MSD, PhDa
a Department of Prosthodontics and Dental Research Institute, School of Dentistry, Seoul
National University, Seoul, Korea
b MAS Program of Digital Dental Technologies, University Clinics of Dental Medicine, Faculty
of Medicine, University of Geneva, Geneva, Switzerland
c Department of Prosthodontics, Seoul St. Mary’s Hospital, College of Medicine, The Catholic
University of Korea, Seoul, Korea
d Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea
*Correspondence:
Prof. Su Young Lee, DDS, MSD, PhD
Department of Prosthodontics, Seoul St. Mary’s Hospital, College of Medicine, The Catholic
University of Korea
Banpo-daero 222, Seocho-gu, Seoul 06591, Korea
Tel.: +82 2 2258 6309
Fax: +82 050 7711 1271
Email: lsuyoung@daum.net
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Submitted August 12, 2020; accepted April 5, 2021
Abstract
Purpose: To evaluate the association between low handgrip strength and type of dental
prosthesis used in Korean adults in a cross-sectional study of nationally representative big data.
Materials and Methods: This study included 7,681 participants aged ≥ 19 years who were
classified into the following four groups: NP (not using a dental prosthesis); FDP (using
tooth-supported or implant-supported fixed dental prostheses); RPD (using removable partial
dentures); and CD (using removable complete dentures). Low handgrip strength was defined as
the lowest quartile of handgrip strength in each sex. The relationship between handgrip strength
and dental prosthesis use was analyzed with adjustment for potential confounders. Multivariate
logistic regression analyses were performed to examine the association between the use of dental
prostheses and low handgrip strength (α = .05). Results: The handgrip strength level of RPD
users was significantly lower than those not using removable dentures (P < .0001). The
respective adjusted odds ratios (with 95% CI) for low handgrip strength in the NP, FDP, RPD,
and CD groups were 1 (reference), 0.90 (0.77, 1.05), 1.44 (1.13, 1.83), and 1.70 (1.29, 2.23) after
adjustment for confounding factors. Using removable partial and/or complete dentures was
associated with a 1.64-fold higher risk of low handgrip strength compared to not using
removable dental prostheses. Conclusions: The use of removable dentures was associated with
low handgrip strength and may be considered a potential risk indicator for functional decline in
Korean adults. Int J Prosthodont 2021. doi: 10.11607/ijp.7334
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1. Introduction
The demand for health care is increasing in pace with the worldwide increase in life expectancy.1
Oral health is closely related to nutrition and quality of life.2-5 If the natural teeth are lost, the
edentulous areas can be restored using fixed or removable dental prostheses. Even in the absence
of oral disease, such as periodontal disease or dental caries, masticatory ability can vary
depending on the type of dental prosthesis used.6-8 Food preferences may also differ according to
masticatory force and performance, resulting in a nutritional imbalance.2,3,9
Dental prostheses can be broadly classified as fixed or removable.10 Fixed dental
prostheses are generally supported by teeth or implants and allow masticatory performance
similar to that of natural dentition. Removable dental prostheses include both partial and
complete dentures. Masticatory ability when wearing removable partial dentures depends on the
length and distribution of the edentulous area and the status of the underlying residual alveolar
ridge. Removable complete dentures are usually used when all natural teeth are lost and are
known to be the least effective of the various types of dental prostheses for chewing.11-13
Therefore, there are differences in masticatory performance according to the type of dental
prosthesis used,11,12 which may be directly related to nutritional status and affect overall
health.14-16
Handgrip strength is the maximum force that can be exerted by a particular muscle or
muscle group. There is accumulating scientific evidence of a significant association between low
handgrip strength and functional decline, nutritional risk, mortality, and poor quality of life.17-20
The method most commonly used to measure handgrip force is the isometric handgrip strength
test, which measures the force of grasping a handgrip dynamometer with one’s hand.21,22 The
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handgrip strength test is widely used as an indicator of functional decline and sarcopenia because
it is relatively simple to perform, and the result can be evaluated in a short time.21-23
Handgrip strength represents the strength of skeletal muscle and has been reported to
have a positive correlation with oral health status, including masticatory strength.24-30
Furthermore, the masticatory force varies depending on the type of dental prosthesis used;11,12
however, few studies have analyzed the association between the type of dental prosthesis used
and handgrip strength.25 The purpose of this study was to analyze the relationship between the
type of dental prosthesis used and handgrip strength based on nationwide big data. The null
hypothesis was that there would be no significant association between the type of dental
prosthesis used and handgrip strength.
2. Methods
2.1. Study participants and enrolment process
The present study examined data from the Sixth Korean National Health and Nutrition
Examination Survey (KNHANES �) 2014 and 2015. This survey is conducted annually to
compile nationally representative cross-sectional big data for monitoring the health and
nutritional status of the Korean population, and is performed by The Korea Centers for Disease
Control and Prevention (KCDC). The purpose of this survey was to calculate national-level
representative and reliable statistics on the health level, health behavior, and food and nutrition
intake of individuals residing in Korea and use them as basic data for national health policy. The
sampling frame for the KNHANES used the data from the latest Population and Housing Census
available at the time of the sampling design. Based on this, a representative sample of citizens
over the age of 1 year residing in Korea, i.e., the target population, was extracted. The survey
protocol was approved by the Institutional Review Board of the KCDC (approval number,
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2013-12EXP-03-5C) and performed in accordance with the tenets of the Declaration of Helsinki.
Informed consent was obtained from all study participants before the investigation was
conducted. Experienced interviewers and inspectors collected the data from the study
participants during interviews and by examination. This study was conducted in accordance with
the STROBE guidelines.31
The KNHANES 2014 and 2015 included 14,930 participants. In the present study, the
data for 11,921 participants aged ≥19 years were analyzed. Of these, 2521 had no information
available for major variables (such as the handgrip strength test and oral examination) and were
thus excluded, as were 1719 further subjects with other missing values such as data on potential
confounders. Ultimately, data of 7681 participants (3425 men, 4256 women) were included (Fig.
1).
2.2. Classification regarding the use of a dental prosthesis
Specially trained dentists performed the oral examinations in all participants. Dental caries,
periodontal disease, and missing teeth were recorded. Oral conditions were recorded separately
for the maxilla and mandible, according to the use of a dental prosthesis due to tooth loss and
whether they were rehabilitated with a fixed dental prosthesis, removable partial denture, and/or
a removable complete denture. Only study participants with dental prostheses due to tooth loss
were included in this study. A fixed dental prosthesis was defined as a bridge-type prosthesis
having one or more pontics. Single crown restorations of natural teeth were not included in the
fixed dental prosthesis category. An implant-supported fixed dental prosthesis, including a single
implant restoration, was included in the fixed dental prosthesis category because it was used to
restore a missing tooth. Study participants with implant-assisted removable partial dentures or
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removable complete dentures were considered to have removable partial dentures or removable
complete dentures, respectively.
Based on the oral examination findings, the participants were divided into a no-prosthesis
(NP) group (with no fixed or removable dental prosthesis due to tooth loss in either the maxilla or
mandible), a fixed dental prosthesis (FDP) group (with one or more conventional or
implant-supported fixed dental prostheses in the maxilla or mandible, but no removable dental
prosthesis), a removable partial denture (RPD) group (with removable partial dentures in the
maxilla and/or mandible, but not removable complete dentures), and a complete denture (CD)
group (with removable complete dentures in either the maxilla or mandible, or both; Fig. 2).
For further analysis, the participants were divided according to whether or not they used
removable prostheses: (1) “no removable dentures” group (including the NP and FDP groups), (2)
“removable dentures” group (including the RPD and CD groups).
2.3. Assessment of grip strength
Participants were excluded from the grip-strength measurement if they were functionally
constrained in a manner that prevented them from undergoing this assessment or showed
discomfort (such as that caused by wrist surgery, or pain within the last 3 months).
After the investigator explained the grip-strength measurement procedure to the participant, the
procedure was demonstrated directly. The participants were asked to remove any jewelry
attached to their fingers or wrists. Next, a light warm-up exercise, entailing shaking both hands
approximately three times, was performed followed by lightly holding all 10 fingers and
releasing them three times. Staring toward the front in a standing position, the arms were
naturally lowered. Grip strength was measured in that position using a digital grip strength
dynamometer (Model T.K.K.5401; Takei, Tokyo, Japan). Starting with the dominant hand, the
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strength was measured in both hands three times in an alternating manner. The grip time was
limited to less than 3 s. Each participant was asked to continue exhaling while holding the grip
strength dynamometer. A 60-s rest period was allowed after each measurement in each hand. The
results were recorded in 0.1-kg units. The highest grip strength value in the dominant hand was
used in this study. Low handgrip strength was defined as the lowest quartile (0–25%) of handgrip
strength within each sex group based on previous studies.18-20
2.4. General characteristics and potential confounders
Basic information, including subject age and sociodemographic lifestyle parameters, were
examined. Household incomes were categorized into four groups, as were education levels.
Current smokers were documented as “smoking status (yes).” Participants who had consumed
alcohol more than twice a month during the past year were recorded as “alcohol consumption
(yes).” Those who undertook at least 2 h 30 min of moderate physical activity or 1 h 15 min of
high intensity physical activity per week were recorded as “exercise (yes).” Body mass index
(BMI) was calculated after measurement of participant weight, height, and waist circumference by
trained inspectors. Participants with a BMI of ≥ 25 kg/m2 were recorded as “obesity (yes).”32
Blood pressure was measured using a mercury sphygmomanometer (Baumanometer;
Baum, Copiague, NY, USA); participants were recorded as having hypertension if they had a
systolic blood pressure of 140 mmHg or higher, a diastolic blood pressure of 90 mmHg or
higher, and/or were receiving antihypertensive medication. Venous blood was collected from
participants who had fasted for more than 8 h, and those with fasting blood glucose levels of 126
mg/dL or higher, those who had been diagnosed with diabetes, and/or those who were on
hypoglycemic agents or receiving insulin injections were considered to have diabetes.33
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“Removable denture requirement” was determined by specially trained dentists. Partially
or fully edentulous dentition, which needed to be restored but could not be restored with a
natural tooth-supported fixed prosthesis, was classified as “removable partial denture required”
or “removable complete denture required.” The participants were included in the “removable
denture requirement (no)” category if they needed neither removable partial nor complete
dentures. If a removable dental prosthesis was already present in the oral cavity but had to be
remanufactured or replaced, the status was classified as “removable denture requirement (yes).”
The participants were asked whether they felt discomfort while chewing food because of
problems with their oral condition, teeth, dental prosthesis, gums, or other related factors. Those
who reported discomfort were included in the “masticatory discomfort (yes)” category.
2.5. Statistical analysis
The SAS survey procedure was utilized to analyze the data obtained by the complex sample
design of the KNHANES and estimate approximations for the entire Korean population. The
characteristics of the study participants were analyzed using analysis of variance (ANOVA) for
continuous variables and the chi-squared test for categorical variables. Handgrip strength levels
according to whether or not a dental prosthesis was present were analyzed as the mean and
standard error using the independent t-test, ANOVA, and analysis of covariance using an
adjusted general linear model. The means were adjusted for sociodemographic characteristics
and systemic health factors in the models. Model 1 was the crude association, and Model 2 was
adjusted for age. Model 3 was adjusted for age, sociodemographic characteristics, systemic
health factors, and removable denture requirement. The fitness of each model was evaluated
using R-square. Multivariate logistic regression analyses were performed to examine the
association between the use of dental prostheses and low handgrip strength. The level of
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handgrip strength was dichotomized (the lowest quartile versus the others in each sex) to perform
the logistic regression analyses and adjusted for the various confounders in the models. All
statistical analyses were conducted using SAS (version 9.3, SAS Institute, Cary, NC, USA). A
P-value <.05 was considered statistically significant.
3. Results
The general characteristics of the study participants according to the type of dental prosthesis
used are shown in Table 1. All potential confounders considered were significantly associated with
the use of dental prostheses (P<.05). The mean age and proportion of subjects with “masticatory
discomfort (yes)” in each group increased significantly in the following order: NP, FDP, RPD, and
CD (P<.001).
Table 2 shows the measured handgrip strength values according to sex and the use of
dental prostheses. A significant association between the use of a removable prosthesis and
handgrip strength was observed even after the final adjustment in Model 3 (adjusted for age,
household income, education level, smoking status, alcohol consumption, exercise, obesity,
hypertension, diabetes, and removable denture requirement). Participants of either sex in the
RPD and CD groups had a significantly lower handgrip strength than those who did not use any
type of removable prosthesis (P<.0001 for both sexes).
The relationship between low handgrip strength and the use of removable dental
prostheses, as examined using the multivariate logistic regression models, is shown in Table 3.
The lowest quartile cut-off value was 36 kg for men and 22.2 kg for women. In the final adjusted
model 3, a significant association between low handgrip strength and the use of a dental
prosthesis remained. When participants were divided into the same four subgroups, the RPD and
CD groups had a 1.44-fold (95% confidence interval [CI] 1.13, 1.83) and 1.7-fold (95% CI 1.29,
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2.23) higher risk of low handgrip strength, respectively, than the participants without dental
prostheses (P=.0016). When the participants with no removable dentures and those with
removable dentures were compared, the latter had a 1.64-fold (95% CI 1.37, 1.97) increased risk
of low handgrip strength (P<.0001).
4. Discussion
This study is potentially the first to investigate handgrip strength according to the type of dental
prostheses worn utilizing a nationwide dataset. A significant association was observed between
handgrip strength and the use of removable prostheses. Therefore, the null hypothesis was rejected.
The adults with removable dentures showed significantly lower handgrip strength than those not
using removable dentures. Furthermore, the risk of low handgrip strength was significantly higher
in study participants with removable dentures than in those who did not use removable dental
prostheses.
Although the relationship between removable dental prostheses and handgrip strength is
still not well studied, several studies have reported a significant association between oral health
status and handgrip strength.24-30 Some of these studies have demonstrated musculoskeletal
frailty with low handgrip strength in patients with poor masticatory performance.24,27,28,30 Even if
the area of tooth loss is restored with a dental prosthesis, masticatory performance may vary
depending on the type of dental prosthesis used.6-8 It has been reported that individuals who use
removable complete dentures have a masticatory force that is 1/7 to 1/4 lower than those with an
intact dentition.11,12 The relatively limited chewing ability in our study participants with
removable dentures may have been associated with reduced handgrip strength and functional
decline.
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The Asian Working Group for Sarcopenia set diagnostic criteria for sarcopenia based on
handgrip strength at <26 kg for men and <18 kg for women.23 Iwasaki et al. reported a significant
association between dentition status and sarcopenia.25 They found that participants without
occlusal pairs of natural teeth had a 3.37-fold higher risk of sarcopenia than those with 10 or more
occlusal pairs of natural teeth.25 Furthermore, a higher risk of sarcopenia was reported in subjects
who used poorly fitting removable dentures than in those with well-fitted removable dentures.25
These results are consistent with the finding of the present study that functional decline and the use
of dental prostheses are related. Inadequate nutrition could be associated with reduced handgrip
strength in individuals wearing removable dentures.34,35 This is because removable denture users
generally prefer soft foods over hard foods that are difficult to chew.36-38
Conversely, reduced handgrip strength can be a cause of oral health problems. Low
handgrip strength is reportedly associated with muscular dystrophy and dexterity limitations.39,40
Reduced hand function and low handgrip strength may also be associated with poor oral self-care
behaviors, such as daily toothbrushing.41-43 These poor oral health behaviors can lead to
periodontal disease44 and tooth loss.45 Therefore, the possibility of using removable prostheses
would be increased. This, in turn, can lead to nutritional restrictions, leading to a vicious cycle
that could cause functional decline.46
Several previous studies have shown that there is a relationship between the number of
natural teeth and handgrip strength.30,47 However, most missing teeth were rehabilitated with
dental prostheses rather than left edentulous. Compared to removable dentures, fixed dental
prostheses, such as implant-supported crowns, have a similar chewing function to that of natural
teeth. Nevertheless, the sites that had been rehabilitated with fixed dental prostheses were often
included in the number of missing teeth in these previous studies.30,47 In such cases, it may be
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12
possible to study the degree of natural tooth loss, but it would be difficult to examine how the
chewing function of the oral cavity affects general health. This is because there is a significant
difference in chewing function between fully edentulous subjects who have both arches restored
with removable complete dentures, and fully edentulous subjects with both arches rehabilitated
with complete-arch implant-supported fixed dental prostheses. Considering these issues, in the
present study, the participant data were analyzed according to the type of dental prostheses used
instead of the number of missing teeth.
This study analyzed a large dataset accumulated by a nationwide survey designed to
predict the health and nutritional status of a national population. This allowed analysis of a body
of well-organized data from a large number of study participants. Furthermore, many potential
confounders were adjusted to examine the independent relationship between the use of
removable prostheses and handgrip strength. However, because this study had a cross-sectional
design, it was impossible to assess causality. Additionally, the levels of handgrip strength
between the groups in the final adjusted model shown in Table 2 were relatively close, although
the difference was statistically significant. Further prospective cohort studies are needed to
elucidate the causal relationship between the use of removable dental prostheses and functional
decline.
5. Conclusions
Within the limitations of this cross-sectional study, the use of removable dental prostheses was
shown to be significantly associated with handgrip strength. The risk of having low handgrip
strength for individuals using removable dental prostheses was 1.64-fold higher than that of
those who did not use removable prostheses, even after adjusting for various potential
confounders including age, household income, education level, smoking status, alcohol
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13
consumption, exercise, obesity, hypertension, diabetes, and removable denture requirement.
Based on the results of the nationwide representative big data analysis in this study, dentists and
physicians may need to consider the potential risk of low muscular strength and functional
decline when examining patients with removable dentures.
FUNDING
This research did not receive any specific grant from funding agencies in the public, commercial,
or not-for-profit sectors.
ACKNOWLEDGMENTS
The authors would like to express their sincere thanks and gratitude to Ms. Da Hye Kim, Mr.
Jin-Hyung Jung, and Prof. Yong-Gyu Park, Department of Biostatistics, College of Medicine,
The Catholic University of Korea, for the review of the statistical analysis.
Conflict of interest statement
The authors declare that there is no conflict of interest.
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Legends to Figures
Figure 1. Flow chart showing the process used to select the study participants.
Overall, 7681 participants were ultimately included. KNHANES, Korean National Health
and Nutrition Examination Survey.
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22
Figure 2. Chart showing the classification of dental prosthesis groups according to the
results of the oral examination.
CD group: at least one removable complete denture; FDP group: at least one fixed dental
prosthesis, including fixed partial dentures and dental implants, but no removable dental
prosthesis; NP group: no dental prosthesis; RPD group: at least one removable partial
denture but no removable complete dentures.
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Table 1. General characteristics of study participants according to the type of dental prosthesis
used.
NP group FDP group
RPD group CD group P-value
n 4437 2328 547 369 Sex (n)
Men 1933 1025 251 216 Women 2504 1303 296 153
Age (years)* 39.3 ± 0.3 53.4 ± 0.4 66.5 ± 0.5 68.6 ± 0.7 <.001 ≥ 70 years 2.2 (0.2) 11.4 (0.7) 41 (2.4) 54 (3.1) <.001
Household income <.001 Lowest quartile 8.9 (0.6) 14.2 (0.9) 37.9 (2.6) 44 (3.2) Lower middle quartile 23.7 (1.1) 23.1 (1.2) 29.9 (2.4) 29.5 (3.1) Upper middle quartile 33.0 (1.2) 30.1 (1.4) 19.4 (2.0) 16.8 (2.5) Highest quartile 34.5 (1.4) 32.7 (1.6) 12.8 (1.8) 9.7 (2.1)
Education level <.001 Elementary or lower 6.7 (0.4) 20.2 (1.0) 50.4 (2.6) 57.6 (3.5) Middle school 6.0 (0.4) 12.9 (0.8) 17.3 (2.0) 16.9 (2.6) High school 41.5 (1.0) 36.5 (1.3) 22.5 (2.1) 19.4 (2.6) College or higher 45.9 (1.1) 30.3 (1.4) 9.8 (1.5) 6.1 (1.7)
Smoking status (yes) 22.3 (0.8) 20.8 (1.0) 17.3 (2.1) 26.3 (2.7) <.05 Alcohol consumption (yes) 51.2 (0.9) 46.6 (1.2) 37.3 (2.3) 36.1 (2.9) <.001 Exercise (yes) 58.3 (0.9) 51.4 (1.3) 41.3 (2.5) 37.8 (2.9) <.001 Obesity (BMI ≥ 25 kg/m2) 30.4 (0.8) 35.1 (1.2) 39.4 (2.3) 37.2 (3.3) <.001 Hypertension (yes) 15.7 (0.7) 33.1 (1.1) 54.7 (2.6) 51.4 (3.3) <.001 Diabetes mellitus (yes) 5.6 (0.4) 11.9 (0.8) 20.8 (2.1) 27.0 (2.7) <.001
Removable denture requirement (no) 95.4 (0.3) 88.7 (0.7) 82.1 (2.0) 85.1 (2.4) <.001
Masticatory discomfort (yes) 12.1 (0.6) 25.1 (1.1) 49 (2.4) 56.3 (3.3) <.001
The data are presented as the weighted percentage (standard error). *Data presented as the mean ± standard error. BMI, body mass index; CD, complete denture; FDP, fixed dental prosthesis, including implant; NP, no dental prosthesis; RPD, removable partial denture
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Table 2. Level of handgrip strength (kg) according to sex and the type of dental prosthesis
used
Group Model 1 Model 2 Model 3 Men No removable denturesa 43.1 ± 0.2 42.0 ± 0.2 40.8 ± 0.3
Removable denturesb 36.6 ± 0.4 38.8 ± 0.4 38.8 ± 0.5
P-value <.0001 <.0001 <.0001 R-square 0.05267 0.1226 0.1947 Women No removable denturesa 26.2 ± 0.1 25.8 ± 0.1 25.7 ± 0.3
Removable denturesb 22.3 ± 0.3 23.6 ± 0.3 24.3 ± 0.4
P-value <.0001 <.0001 <.0001 R-square 0.04322 0.08402 0.1331
Men NP 43.5 ± 0.2 41.8 ± 0.2 40.7 ± 0.4
FDP 42.1 ± 0.3 42.3 ± 0.3 41.1 ± 0.4
RPD 37.0 ± 0.5 39.3 ± 0.5 38.9 ± 0.5
CD 36.2 ± 0.6 38.6 ± 0.6 38.7 ± 0.6
P for trend <.0001 <.0001 <.0001 R-square 0.05969 0.1237 0.1952 Women NP 26.4 ± 0.1 25.7 ± 0.1 25.6 ± 0.3
FDP 25.6 ± 0.2 25.9 ± 0.2 25.8 ± 0.3
RPD 22.8 ± 0.3 23.9 ± 0.3 24.6 ± 0.4
CD 21.5 ± 0.5 22.9 ± 0.5 23.8 ± 0.6
P for trend <.0001 <.0001 <.0001 R-square 0.05044 0.08491 0.1338 Data are presented as mean ± standard error. aNP and FDP groups combined. bRPD and CD groups combined. CD, complete denture; FDP, fixed dental prosthesis, including implant; NP, no dental prosthesis; RPD, removable partial denture. Model 1 is the unadjusted association, Model 2 is adjusted for age, and Model 3 is adjusted for age, household income, education level, smoking status, alcohol consumption, exercise, obesity, hypertension, diabetes, and removable denture requirement.
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Table 3. Odds ratios for study participants with low handgrip strength according to the type
of dental prosthesis used
Group Model 1 Model 2 Model 3
No removable denturesa 1 (ref.) 1 (ref.) 1 (ref.) Removable denturesb 4.16 (3.5, 4.95) 1.93 (1.61, 2.3) 1.64 (1.37, 1.97) P-value <.0001 <.0001 <.0001 R-squarec 0.0497 0.1085 0.1527
NP 1 (ref.) 1 (ref.) 1 (ref.) FDP 1.46 (1.26, 1.69) 0.88 (0.76, 1.03) 0.9 (0.77, 1.05) RPD 4.22 (3.4, 5.24) 1.66 (1.32, 2.08) 1.44 (1.13, 1.83) CD 5.42 (4.15, 7.08) 2 (1.53, 2.62) 1.7 (1.29, 2.23) P for trend <.0001 <.0001 0.0016 R-squarec 0.0566 0.1092 0.1533 The data are presented as the odds ratio (95% confidence interval). The low handgrip strength was defined as the lowest quartile (cut-off value was 36 kg for men and 22.2 kg for women). aNP and FDP groups combined. bRPD and CD groups combined. cNagelkerke R-square. CD, complete denture; FDP, fixed dental prosthesis, including implant; NP, no dental prosthesis; RPD, removable partial denture. Model 1 is the unadjusted association, Model 2 is adjusted for age, and Model 3 is adjusted for age, household income, education level, smoking status, alcohol consumption, exercise, obesity, hypertension, diabetes, and removable denture requirement.
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